Medicaid is a needs-based program which was created by Congress to help pay for
medical care for those aged and disabled persons, as well as poor children and
their caretaker relatives, who meet the very strict eligibility criteria.
Medicaid policies can be complex. They change frequently, and at the
present time, many changes to the Medicaid program are being debated on both
the federal and state levels. This information about the eligibility
rules and benefits provided through the Medicaid program for people who live in
their own homes is accurate as of January 2006. Information regarding
Medicaid eligibility for nursing home care and long-term home care (Connecticut
Home Care Program for Elders) is also available from the Center for Medicare
Advocacy.
Medicaid is jointly financed by the federal and state governments, and is
administered in Connecticut
by the Department of Social Services. Connecticut is required to adhere to the
basic eligibility and benefits requirements contained in the federal statute
and regulations. The Department of Social Services has developed its own
regulations and policies interpreting the federal rules.
How Does Medicaid Differ From Medicare?
While Medicaid, like Medicare, affords access to health care services, it is
very different from Medicare in a number of key areas. Persons are only
eligible for Medicaid if they satisfy both the financial and non-financial
eligibility rules. In general, Medicaid is only available for individuals
who do not have sufficient income and assets to pay for their own medical
treatment. However, Medicaid is not available to all such
individuals. Only certain people; those who are 65 years of age or older,
disabled as defined by the rules governing Social Security disability benefits,
young children or their caretaker relatives may qualify for Medicaid.
Unlike Medicaid, often called Title 19 in Connecticut, eligibility for Medicare is not
predicated upon the income or assets of the beneficiary.
Medicaid covers far more nursing home care than Medicare, since it pays for
custodial as well as skilled long-term care and has no limits as to how long a
period of care is covered for an eligible individual. Significantly both
programs can be a source of funding for long-term home care. Medicare
only covers home health care if the individual is homebound and needs some
skilled nursing or therapy services. Medicaid does not require that a
person be homebound to get home health benefits, nor does Medicaid require that
the person need a skilled service to qualify for home care services.
MEDICAID ELIGIBILITY
Introduction
The Medicaid financial eligibility rules differ depending upon the living
arrangement of the applicant. The rules for establishing eligibility for
Medicaid for a person living in her own home are very different from the rules
governing eligibility for those residing permanently in nursing homes. A
special home care program, called level 3 of the Connecticut Home Care Program
for Elders, uses the more liberal long-term care (i.e. nursing home) eligibility
rules.
Community Eligibility: Income Eligibility
For a person living at home, income must be very limited to meet the Medicaid
eligibility rules. In most of the state of Connecticut, an individual's income may be
no more than $476.00 per month, including the standard unearned income
disregard of $207.00 per month. The exact amount depends upon where in
the state the applicant resides. A chart at the end of this section
provides the specific amount of income permitted for each region. There
are a number of deductions which may be made from income. All aged,
disabled and blind persons are entitled to a deduction from unearned income,
such as Social Security check, of $207.00 per month. In addition, the
amount of the Medicare Part B Premium may also be deducted from gross income
except in establishing eligibility for the qualified Medicare beneficiary (QMB)
and specified low income Medicare beneficiary (SLMB) programs. (See the
section on those programs.) There are also deductions from earned
income. The eligibility of individuals on T19 residing in nursing homes
or receiving home health care through the Connecticut Home Care Program for
Elders are very different. (See the section on long-term care Medicaid
eligibility.)
"Spend Down" Eligibility
Persons who meet all of the other Medicaid eligibility rules, but whose incomes
are too high are permitted to "spend down" their income to establish
Medicaid eligibility for 6 month periods of time. The "spend
down" is similar in concept to a deductible amount in health
insurance. "Spending down" is done by incurring or paying
medical bills in an amount equal to six times the amount by which income
exceeds the Medicaid allowable limit. Proof of the bills
incurred or paid must be submitted to the Department of Social Services.
After the person's "spend down" has been accomplished, Medicaid will
cover the individual's Medicaid-coverable medical care for the rest of
the 6 month period.
Qualified Medicare Beneficiary/Specified Low Income Beneficiary Programs
The Qualified Medicare Beneficiary and Specified Low Income Medicare
Beneficiary Programs provide additional ways to establish eligibility for some
Medicaid coverage while living at home. (See the section describing those
programs for eligibility and coverage information.)
Community Eligibility: Assets
In Connecticut, the resources (or accumulated wealth) that one may maintain
without affecting eligibility for Medicaid (Title 19) benefits while living at
home are:
a home;
personal assets (cash, bank
accounts, stocks, bonds), up to a total value of no more than $1,600 for
an individual or $2,400 for married couples;
an allowance towards funeral
and burial expenses (including a burial fund, life insurance, etc.) the
total value of which may not exceed $1,200 or a $5,400 irrevocable
contract with a funeral home;
the value of one burial plot
per individual applicant.
HEALTH CARE SERVICES FUNDED BY THE CONNECTICUT
MEDICAID PROGRAM INCLUDE:
Inpatient hospital services
Outpatient hospital services
Laboratory and X-ray
services, including radiation therapy
Physician's services
Podiatric services
Naturopathic services
Vision care
Family planning services
Home health services
Certain chiropractic services
Health clinic services
Early Periodic Screening,
Diagnosis and Treatment (EPSDT)
Dental services, including
orthodontia services
Maternity clinic services
Ambulatory surgical center
facility services
Emergency hospital services
Hearing aids and certain
hearing aid services
Mental health services
Nursing facility services
Psychiatric hospital services
Some home care services
Prescribed drugs
Medical transportation
Durable medical equipment
Home and community based
services
School based child health
care
Midwives
Nurse practitioners (soon to
be authorized as providers)
